Oral health guidelines in the primary

care policies of five selected

countries: An integrative review

S.ghalichebaf
Introduction

 João Victor Inglês de Lara , Paulo Frazão

 Health policy open
 Public Health Postgraduate Program, Public Health School at University of São
Paulo (USP), São Paulo, Brazil
 Department of Politics, Management and Health, Public Health School at
University of São Paulo (USP), Av. Doutor Arnaldo, 715, São Paulo, SP 01246-
904, Brazil
ABSTRACT

 Background
 Aim
 Methods
 Results
 Conclusion
background

 Oral health conditions remain highly prevalent worldwide

 The establishment of an integrated health system is described as a way to
produce optimal health outcomes and reduce inequities based on universal
access and social protection
 After more than 40 years of the Alma‐Ata Declaration publication, to examine
the oral health component of PHC guidelines and the documents that
substantiate its implementation is an important way to support decision‐
makers, policy‐makers
 Therefore, this paper aimed to summarize oral health guidelines focused on
the comprehensiveness component of PHC in the health system and on the
intersectoral component of health promotion and disease prevention actions
in five selected countries.
Methods

 “What are the characteristics of the comprehensiveness component and on

the intersectoral component among primary care policies in five countries
with universal health systems and traditional PHC?”
2.1. Country selection

 We selected countries driven by multiparty capitalist democracies whose current health

system guarantees the right to health to all citizens independent of their ability to pay or
have healthcare schemes described as being universal in scope. The organization of health
systems should be based on the PHC model for more than 20 years since the research year
(2016).
 United Kingdom, Australia, New Zealand and Canada were included.
 for all United Kingdom citizens. Private insurance plays a minor role, accounting for about
ten percent of coverage
 Australia and New Zealand have a mixed private–public system with many cost‐sharing
requirements
 Canada provides universal public insurance plan, which prohibits private health insurance
use to pay for services covered by the public plan
 Brazil has gained international recognition for its public health system based on PHC that
integrates oral health
2.2. Eligible publication types

 Assuming that important texts on the subject of interest are present in form
of technical documents not indexed in databases, studies from all designs and
technical documents from grey literature as policy guidelines, reports,
frameworks, plans and strategies were considered eligible for the review
2.3. Literature database

 The scientific databases Embase (Excerpta Medica dataBASE), MEDLINE

(Medical Literature Analysis and Retrieval System Online) and LILACS (Latin
American and Caribbean Health Sciences Literature) were selected for
covering the selected countries in their scope and their relevance to health
science in general and public health in particular
2.4. Literature search strategies

 The database search strategies were constructed according to databases

specific terms and were combined with Boolean terms ‘AND’ or ‘OR’ (Annex
A). We conducted the search in MEDLINE database using the PubMed tool.
2.5. Selection criteria

 Documents in English, Portuguese, Spanish and French were considered in the

classification process. The initial period was set from 2000 to 15th December
2016.
 For scientific documents, the inclusion criteria were: theme related to the
review question; summary presence; and availability online or through
manual search. Duplicates were excluded. For technical documents, the
inclusion criteria were: theme related to the review question; governmental,
professional or research entity authorship; and references from the literature.
Dissertations and thesis were excluded. The inclusion criteria were applied by
two reviewers and the level of consistency was 0.82 measured through Kappa
statistic in the title and abstracts screening phase. Disagreements were
debated and defined by consensus
2.6. Methodological quality assessment

 To assess methodological quality, documents were analysed according to their

relevance to the field, clarity of presentation, rigor of the content and
theoretical framework adopted, and editorial independence. For technical
documents, authorship analysis was also performed to identify documents
supported by governments, professional or research entities. Non‐conforming
documents were excluded and those selected to compose the review had
their references screened
2.7. Data extraction and category
definition for analysis
 We performed data extraction and tabulation using a synthesis matrix,
elaborated from three categories previously defined. First, “oral health in the
health system” explored and compared general characteristics of the oral
health services coverage in the selected countries. Second,
“comprehensiveness of care”, sought out guidelines that ensured oral health
services provision according to individuals, families and communities needs.
 The third category, “health promotion and disease prevention actions”,
summarized content related to promotion and prevention services,
programmes and activities
Results

 The search resulted in 788

registers. After title and abstract
screening and exclusion of
documents not related to the
review question, 78 documents
were included for full‐text
screening. In the light of inclusion
and exclusion criteria, the quality
assessment and reference
screening process, 41 documents
were eligible for the review, 20
from scientific literature and 21
from grey literature. The selection
flowchart is presented in Fig. 1.
3.1. Characteristics of the documents

 Among included documents, nine (22%) refer to Australia, five (12%) to

Canada, four (11%) to New Zealand, 13 (31%) to the United Kingdom and ten
(24%) to Brazil
3.2. Oral health in the health system

 The oral healthcare supply in the public health system varied among
countries, all of which have in common a public–private mix. In Australia,
Canada and New Zealand, oral health care is mainly provided by private
providers, and the financing of services depended on the user's ability to pay.
Public providers play a minor role and offered limited treatments, focused on
urgent needs and some basic procedures at the primary care level. These
services were focused on vulnerable population groups such as children,
teenagers, pregnant women, low‐income adults, people living in regional and
remote areas, people with disabilities and certain ethnic groups (e.g.,
Aboriginals and Torres Strait Islander people in Australia, Maori and Pacific
people in New Zealand and Ontario First Nations in Canada) .The coverage of
these services varies according to the territory. The funding could be fully
public or based on co‐payments
 Access was different in the United Kingdom and Brazil, where oral care is
guaranteed as a right and is delivered as part of PHC. In the United Kingdom,
the right to access a dentist is in the National Health Service (NHS)
constitution. However, dental services availability, coverage and extent varied
according to territory, and users are responsible for part of the financing
through co‐payments.
 In Brazil, the public health system, known as Unified Health System (Sistema
Único de Saúde ‐ SUS), also offered universal access to dental services
through a public primary care network (two‐thirds of their units had at least a
general dental practitioner), supported by approximately one thousand dental
specialty centres . Despite state‐ funded services, the private sector was
dominant in the oral health services provision.
3.3. Comprehensiveness of care

 Comprehensiveness of care was cited in 34 documents (Table 1) referring to

horizontal dimension in most of them (33/34). The most observed trend was
to consider oral health services as an integral part of general health. There
was convergence regarding the oral health services presence along with other
services in PHC.
 Regarding the integration of care levels and several different health
disciplines, the need for information systems capable of systematically
gathering data has been recognized. The creation of a data source seems to
be essential for guiding health practice, building scientific evidence and
producing effective public policies
3.4. Health promotion and disease
prevention actions
 The guidelines concerning health promotion and disease prevention actions
described their potential to reduce inequities by dealing with social,
economic, commercial, and environmental determinants of health (Table 2). A
common aspect was the need to include oral health among general health
actions . To organize these actions, the common risk factors approach was
highlighted.
 such as family physicians, paediatricians and nurses, that includes
mouthguards use during sports; breastfeeding; smoking cessation programs;
blood pressure checks; sugar‐free chewing gum and new‐borns microbiota
control by parents and guardian
 The subcategory 'intersectoral actions' encompassed actions that depend on
government and society sectors other than the health sector. Among them,
mentioned measures were: water supply fluoridation, educational actions
focused on health, welfare policies, healthy‐ eating promotion strategies, and
strong interactions between the health sector and other sectors, such as
agricultural, industrial, transport, education and media sectors. Fluoridation
was the action with greatest emphasis on results, and documents described
efforts to maintain and extend its reach
Discussion

 In Brazil, guidelines reinforced the oral health integration into PHC policy;
however, implementation of actions depended on the local authority and
faced a conflictive context involving different local arrangements of PHC [51].
The need to overcome challenges and strengthen oral health within PHC in
order to decrease oral diseases prevalence was a shared point in the
documents
 The trend towards health care integration in response to the increase in
chronic diseases and comorbidities characterizes the guidelines. The findings
suggest a complex process that relies on multiple components to be effective,
including efforts to manage health systems and their services according to
population needs
 Health promotion and disease prevention actions were commonly described in
the guidelines. These actions shift practices from a dominant model focused
on disease treatment to a new health care model, based on individuals,
families and community’s needs. This approach is strongly recommended as
the most effective way to reduce health inequities worldwide . Intersectoral
strategies were highlighted as a way to reorient health services and create
public policy through common risk factors approach to promote oral health.
This is strongly recommended as an effective chronic diseases control method
and as an opportunity to expand actions to oral health activities in addition to
other health fields and policy sectors
 Among intersectoral actions, water fluoridation continues to be the most
recommended, justified as the most cost‐effective measure and as capable of
reducing inequities . The importance of programmes aimed at ensuring access
to fluoride toothpaste was unanimous
 In this integrative review, main guidelines published in scientific and grey literature
between 2000 and 2016 were gathered, in order to highlight and compare general
principles that guide formulation and implementation of the oral health component
in primary care policies. Strategies and means to facilitate this component’s
incorporation, such as oral health care information systems integration with other
health information systems and the structuring of transparent systems of
accountability, liaison, linkages and partnerships with other health agencies for
monitoring, evaluation and ensuring service responsiveness, were not highlighted.
The comparison of health systems is complex precisely because of particularities that
surround them. In the United Kingdom, the devolution process that began in 1998
enabled each country to refocus its health policy development in accordance with
local governments, prompting England to incorporate free choice and competition
mechanisms, while Scotland, Northern Ireland and Wales focused on mutuality and
partnership. These particularities were not addressed, and the option of studying the
United Kingdom as a unit was provided by similarities in the core policies of the four
countries, which share most of the NHS guidelines . Furthermore, comparative
analyses are necessary to highlight differences and similarities in the subject, and
narrative synthesis is a way of elucidating contexts and allowing the reader to be
clear about the complexity surrounding the results. The methodological rigor and the
explicit description of the steps and procedures adopted sought to minimize the
effect of possible biases, enabling this study to serve as a basis for improving the oral
health component of PHC policies at local, regional and national levels
Conclusion
 More than forty years after the publication of the Alma‐Ata Declaration, the oral
health integration into PHC policies remains a challenge. The findings revealed
recommendations pertinent to this guideline in the five countries. Formulations in the
UK and Brazil suggest that oral health integration into PHC policies is at a more
advanced stage in those countries than in Australia, Canada, and New Zealand, where
difficulties persist in implementing oral health as part of the health system.
 Intersectoral policies and actions oriented towards health promotion and disease
prevention are recognized as an effective way to insert oral health into the general
health context and other sectors. Water fluoridation is one of the most mentioned
strategies because of its potential to reduce inequalities. Actions in cooperation with
the education sector are well described, while interaction with other sectors is more
complex and receives less attention. The fluoride toothpaste importance is
unanimously cited. The common risk factors approach is mentioned as an important
concept for guiding and planning health promotion and disease prevention actions.
The oral health guidelines identified in the PHC policies of five selected countries
represent an important source of information, and its synthesis formulated using the
integrative review method is a significant instrument to support decision‐makers,
policy‐makers and stakeholders
 Funding This work was supported by Conselho Nacional de
Desenvolvimento Científico
 Declaration of Competing Interest The authors declare that they
have no competing interests that could have influence the work
reported in this paper
Thanks for the attention